Register Online

Complete this registration form so we can make an appointment for you.

We realise the form is quite long but we need to ensure that we know enough information to provide you with the best treatment possible when you come in.

Personal Registration Form
  1. The information entered in this form is Strictly Confidential and will never be given to anyone outside of Henderson Periodontics and Implants
  2. Salutation

  3. (required)
  4. (required)
  5. (required)
  6. Gender
Contact Details
  1. (required)
  2. Preferred Contact
  3. (valid email required)
Your Professionals Details
Emergency Contact Details
Your Medical History
  1. Are you at present having any medical treatment
  2. Have you ever had a serious illness
  3. Have you ever been in hospital as a patient
  4. Have you had any joints replaced
  5. Have you ever had a heart condition or high blood pressure
  6. Are you taking any medicine tablets or drugs including herbals
  7. Do you smoke cigarettes
  8. Have you any known allergies or had any reaction to medicines
  9. Have you ever had any treatment for excessive bleeding
  10. Have you ever had contact with HIV
  11. If female are you pregnant
  12. Have you ever had

Where did you hear about us
Acknowledgement
  1. Having completed this form, being the patient, parent or guardian of the above minor patient, believe that the above information is correct to the best of my knowledge and agree to advise any changes to my health in the future.
  2. Please note a fee of $50 for each half-hour appointment may be charged if you fail to attend your scheduled appointment or if you cancel your appointment within 24 hours.
Confirmation
 

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